Surgical management of tubal obstruction at the uterotubal junction

Abstract

"The surgeon who works in the sterile tube will get the best results from the operation that produces at least one good tube next to one good ovary, with the minimum of surgical trauma, and the minimal number of stitches." This comment by Grant in 1971 also holds true today as infertility surgeons strive through new techniques and instrumentation to give renewed reproductive potential to all varieties of diseased and occluded fallopian tubes. It is our observation (certainly shared by others) from personal experience and from the literature that, assuming all other fertility factors are functionally normal, there are only three conditions that need to be met by reconstructed tubes to offer the possibility of pregnancy: (1) the final length of the tube must be sufficient to reach from the uterus to the site of ovum pickup, whether the ovary or the cul-de-sac; (2) there must be sufficient mucosal amount and function to produce the oviductal secretions that regulate and support the sperm, ovum, and conceptus; and (3) there must be sufficient tubal function to delay morula or blastocyst transport until the endometrium is prepared for implantation. It is apparent from this review that all varieties of UTJ reconstructive operations have proven their potential to endow the postoperative tube with the above requirements for pregnancy, despite the fact that many result in the removal or bypass of large segments of proximal and mid-segment tubal tissue thought to be important in the normal reproductive process. Therefore, the hesitancy and lack of enthusiasm that once existed to tackle cornual and isthmic occlusions should no longer be as widespread. There will always be a place for whatever favorite procedure works best in one's hands, because the technique of the surgeon is probably more important than the type of UTJ procedure, but it is our opinion that microsurgical tubocornual anastomosis should be one's primary approach to correcting a UTJ obstruction. Microanastomosis has been consistently more successful than implantation techniques, is associated with fewer postoperative complications, and is designed to conserve maximum amounts of normal cornual and tubal tissue. However, given the circumstances of complete intramural occlusion or surgeon preference, any of the described uterotubal implantation operations can be confidentiality utilized as a primary or secondary approach to surgical reconstruction of UTJ obstructions.